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NUR 103 > Unit 2 > Flashcards

Unit 2 Flashcards

1
Q

Complications from burns

A

CONTRACTURES, infection, shock

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2
Q

When doing dressing changes for burns always remeber to use

A

sterile technique

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3
Q

Cherry red mucosa is a tell tale sign of

A

Carbon monoxide posioning

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4
Q

How would you propritize tx after a massive trauma?

A
  1. Airway
  2. Other injuries
  3. Burns
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5
Q

How to prevent contractures?

A

ROM

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6
Q

Dietary considerations for Burn pts

A

High calorie high protein

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7
Q

Herniated nucleus pulposus

A

herniated disc

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8
Q

Pt presents with severe pain, muscle spasms, numbness/tingling, decreased reflexes, or sciatic nerve pain…What do you suspect the dx is?

A

Herniated disc

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9
Q

tx for herniated disc

A 
RICE 1-2 days
heat after 2 days
medications
ultrasound tx
PT for back strengthening exercises
swimming
PT
Chiropractic care
surgery
when laying on back use pillow to elevate legs to take pressur eoff back
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10
Q

If a spinal cord injury is suspected to be incomplete you know what about their condition?

A

That it cannot be fully assessed until the swelling goes down

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11
Q

Complications associated with a spinal cord injury

A

PRIORITY IS AIRWAY
spinal shock
neurogenic shock
muscle spasms

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12
Q

What to remember when a pt is taking prednisone?

A

they need to be tapered off of it

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13
Q

most common muscle relaxer used amongst SCI pts.

A

baclofen

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14
Q

Used to help tx low blood pressure (think SCI pt’s

A

dopamine

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15
Q

Nursing interventions for pts with a spinal cord injury

A

pt is a fall risk
assess bladder
prevent pressure ulcer

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16
Q

pt presents with sudden onset of HIGH BP, has a distended bladder, has a spinal cord innjury at T6…what could be the diagnosis

A

Autonomic dysreflexia

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17
Q

If autonomic dysreflexia is suspected what should be done FIRST

A

Raise the HOB

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18
Q

If a spinal cord injury is suspected what is the PRIORITY action?

A

Do NOT move them unless they are in immediate danger. Wait for EMS to come with stabalizing equipment

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19
Q

What is the usual first sign of infection in older adults

A

confusion

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20
Q

What is a major sign of parkinsons disease

A

resting tremor

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21
Q

A pt with parkinsons usually has trouple reading but does better writing why?

A

Resting tremors eases up with intentional movement

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22
Q

Nursing care for pt’s with parkinsons

A 
Fall risk
drug therapy (sinamet)
PT
A lot of emotional support
neurosurgery electrical implants to shock and block tremors
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23
Q

Drug that enhances the delivery of dopamine to the brain cells. Used to tx the symptoms of parkinsons

A

sinemet

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24
Q

A parkinsons comes into the ER and daughter states since taking her new meds the pt presents with GI complications, palpitations, urinary retention, behavioral changes, severe nausea, vomiting, increased gambling, sexual binge or compulsive eating or other intense urges what do you suspect?

A

Sinemet toxicity

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25
Q

Why should sinement pts report leasions to their PCP

A

it can cause a malignant melinoma

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26
Q

The spontaneous separation of an incision (often abd), involved separation of the layers beneath the skin as well

A

Dehiscence

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27
Q

A pt has just experiencenced dehiscence of his abd incision. What is the first thing you do?

A

Cover with a wet sterile dression or cloth

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28
Q

Protrusion of an internal organ through the incision

A

evisceration

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29
Q

Pt presents with:

T: >100.4 F <96.8 F.4 F
RR: > 20
HR: > 90
WBC: < 4,000 or >12,000 or > 10% bands
PCO2: <32 mmHg—low bc of hyperventilation

What do you suspect?

A

SIRS

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30
Q

Pt presents with:

T: >100.4 F <96.8 F.4 F
RR: > 20
HR: > 90
WBC: < 4,000 or >12,000 or > 10% bands
PCO2: <32 mmHg—low bc of hyperventilation
confirmed or suspected infection
Change in LOC
decreased platelets
elevated leukocytes
elevted lactate
increase in pain
A

sepsis

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31
Q

Pt is showing signs of:

Change in LOC
decreased urine output
decreased intake or onset of N/V
increased pain
lab and vital sign changes

can be clasified as doing what?

A

decompensating

32
Q

Pt presents with severe sepsis w/ persistent hypotension, S/S of end organ damage
Lact >4

A

septic shock

33
Q

pt presents with the following:

 RUQ pain progressing to the lover back
 Clay colored stool that will float because of indegested fat
 N/V
 Severe pain
 Possible fever
 Bile backs up into liver jaundice may occur

What could the dx be?

A

Gallbladder disease

34
Q

Dx testing for Galbladder disease

A

 Labs: increased white count
 Ultrasound
 HIDA scan
 CT scan

35
Q

If a pt that has had a recent cholecystectomy is complaining of shoulder pain what should you do?

A

Walk them around. It’s probably trapped gas

36
Q

Pt presents with the following:

High BP
edema
periorbital edema (puffy around the eyes)

What can the nurse suspect the pts dx to be?

A

Glomerulpnephritis

37
Q

What kind of diet do glomerulonephritis pts need to be on?

A

low protein; low sodium

38
Q

A TB test with swelling at the site more than 5mm

A

Positive

39
Q

A TB test with an induration less than 5mm

A

negative

40
Q

WHen transporting a pt with TB what should you always make sure the pt is wearing?

A

a surgical mask

41
Q

A home health nurse is dispatched to collect what kind of culture to ensure the tx is working and the pt is compliant

A

Sputum culture

42
Q

Pt presents with the following:

 5-10 diarrhea/blood stools a day, abd pain, rectal pain, rectal bleeding, fecal urgency, fever, weight loss, vomiting, fatigue, dehydration, cramping

What can the nurse suspect the pts dx to be?

A

Ulcerative colitis

43
Q

Nursing interventions for ulcerative colitis

A

 Pain control, monitor potassium, I&O’s, low fat and fiber diet, high calorie and protein encouraged, small amounts of food with lactose (dairy)

44
Q

Treatment for ulcerative colitis

A

 No medical cure; surgical cure which required the section of bowel to be removed

45
Q

How to tx diverticulitis

A

High fiber diet, increased fluids, stool softener, surgical removal of affected part of the colon, anastomosis, colostomy, take-down

46
Q

Center eye blindness

A

maclar degeneration

47
Q

What kind of shock can you anticipate from a burn?

A

hypovolemic shock

48
Q

What kinf of electrolyre imbalances can you anticipate from a severe burn?

A

hyponatremia

hyperkalemia

49
Q

Best method of looking for carbonmonixide poisoning?

A

ABG

50
Q

If burn is smoldering what do you put on it?

A

Tepid water

51
Q

Dietary considerations for burn patients

A

High calorie

high protein

52
Q

S/S associated with a lumbar injury

A

sciatic nerve pain, decreased nerve reflexes below the waste. No S/S in hands and arms.

53
Q

pt presents with

sciatic nerve pain, decreased nerve reflexes below the waste. No S/S in hands and arms.

what do you suspect is the dx?

A

lumbar injury

54
Q

S/S associated with a cervical injury

A

difficulty breathing depending on how high the injury is. Numbness and tingling in the hands and arms.

55
Q

Main S/S of parkinsons

A 
Resting tremor
shuffling gait
slow movement
poor balance
muscle rigidity
56
Q

Diet for a glucomephritis pt

A

low protein
low sodium
restrict fluids

57
Q

TB results should be read within

A

48-72 hrs

58
Q

What test is used to check for remission of tb?

A

Sputum culture

59
Q

If a pt who has TB has any sort of mental impairment, a previous dx that is untreated, or is confused, anticipate what?

A

Going into the home to ensure they are compliant with their medications

60
Q

Diet for patient with unlcerative colitis

A

Low fat and low fiber diet, high calorie and high protein
Small amounts of lactose
If NPO for a long period of time expect TPN

61
Q

Ulcerative colitis puts pt at risk for what kind of cancer?

A

Colon

62
Q

If a ulcerative colitis pt has a lot of bleeding what should you suspect?

A

anemia

63
Q

Nursing interventions for ulcerative colitis

A 
Fluid resusitation
pain control
monitor potassium
Strict I&O
Diet
64
Q

tx for diverticulosis

A

High fiber diet, increased fluids, stool softener, surgical removal of affected part of the colon, anastomosis, colostomy, take-down

65
Q

What kind of macular degeneration is more common with age?

A

dry

66
Q

Risk factors for cateracts

A

smoke, excessive alcohol use, eye surgery, eye trauma, poor nutrition

67
Q

S/S of cataracts

A

blurry vision, colors will appear less vivid, halos, inability to read small print

68
Q

pt presents with:

blurry vision, colors will appear less vivid, halos, inability to read small print

What do you suspect the dx is?

A

cataracts

69
Q

risk factors of retinopathy

A

underlying conditions; hypertension, diabetes, hereditary, smoking

70
Q

S/S of Open angle glaucoma

A

more common, angle between iris and sclera, aquoes humor outflow is decreased due to blockage. Seek help immediately, headache, mild eye pain, loss of peripheral vision, decrease accomadation, halos around light, elevated IOP of more that 21mm. No. 1 risk factor is age. Onset is more gradual

71
Q

S/S of closed angle glaucoma

A

angle between iris and sclera suddenly closes causing IOP 30mm or higher, decreased/blurry vision, colored halos around lights, pupils nonreactive to light, severe pain and nausea, photophobia. Onset is more sudden

72
Q

S/S of open angle glaucoma

A

angle between iris and sclera suddenly closes causing IOP 30mm or higher, decreased/blurry vision, colored halos around lights, pupils nonreactive to light, severe pain and nausea, photophobia. Onset is more sudden

73
Q

S/S of glaucoma

A

aching of eyes, head ache, halos, visual changes, nor corrected with glasses

74
Q

Pt presents with:

aching of eyes, head ache, halos, visual changes, nor corrected with glasses

What do you expect the dx to be?

A

glaucoma

75
Q

What medication should you avoid if you have closed angle glacoma?

A

antihistamines

NUR 103 (5 decks)

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